A two-month study of the effects of oral irrigation

and automatic toothbrush use in an adult orthodontic

population with fixed appliances
James G. Burch, DDS, MS,· Richard Lanese, PhD,b and Peter Ngan, DMDc
Columbus, Ohio

Forty-seven adult orthodontic patients with fixed orthodontic appliances were divided into three study
groups: (1) oral irrigation with automatic toothbrush, (n = 16); (2) oral irrigation with manual
toothbrushing, (n = 16); (3) control group with continued normal toothbrushing only, (n = 15).
Gingival and plaque indices, bleeding after probing, and gingival sulcus depths were assessed at
baseline, 1-month, and 2-month periods. Marked and significant gingival and plaque improvements
from baseline were measured in all three study groups. After 1 to 2 months use of the automatic
toothbrush and/or the oral irrigation device, there was a significant reduction in plaque when
compared with the control group who used only the manual toothbrush (p = 0.026). Also, there was
a significant reduction in gingival inflammation (p = 0.045) and evidence for reduced bleeding after
probing (p = 0.037). No significant differences were found in probe depths among the three study
groups, however, use of both devices reduced the pocket depth significantly from baseline by 0.5
mm (p < 0.0002). For this population of orthodontic patients, significant reductions in plaque,
gingival inflammation, and a tendency for reduced bleeding after probing occurred in both groups
with the power device. These improvements were most attributable to the effect of the oral irrigation
device. (AM J ORTHOD DENTOFAC ORTHOP 1994;106:121-6.)

Fixed orthodontic appliances impair plaque
removal, oral hygiene, and gingival health. Plaque is
harbored by the appliances, and hinders its removal.
Gingivitis develops and can become quite profound in
21 days.' The gingivitis can be reversed in 5 days by
thorough plaque removal. 2 Because of interferences in
plaque removal by the fixed orthodontic appliances,
adjunctive aids and plaque removal devices become
helpful in regaining or maintaining gingival health. Wa-
ter irrigation devices and automatic toothbrushes have
been considered beneficial adjuncts to normal manual
toothbrushing and plaque removal.
Removal of some plaque from specific surfaces of
various teeth can be achieved with a normal manual
toothbrush.':" The use of power toothbrushes by ortho-
dontic patients has also been reported. A few of these
publications report significant benefits. However, other
investigators report no differences between the use of
a power brush and a manual toothbrush. Various fea-
tures of automatic toothbrushes have been tested and
Fromthe Ohio State University.
'Professor, Department of Orthodontics, College of Dentistry.
'Professor, Department of Preventive Medicine, College of Medicine.
'Associate Professor, Department of Orthodontics, College of Dentistry.
Copyright © 1994 by the American Association of Orthodontists.
0889-5406/94/$3.00 + 0 8/1/43788
reported, as well. Brush head design reportedly is a
useful feature, especially in proximal areas.P:" How-
ever, a patient with normal dexterity and reasonable
sensitivity tolerance can achieve good plaque removal
and maintain good gingival health no matter what
method is used."!"
Oral irrigation devices with a pulsating stream of
water directed through a tip orifice to specific tooth
surfaces have been shown to clean teeth and appliances
of bacteria and debris, They also help retard accumu-
lation of plaque and calculus, thus reducing gingival
inflammation. Water irrigation causes minimal trauma
to diseased soft tissues, but reportedly does not induce
bacteremia when used according to the manufacturer's
instructions in patients with gingivitis. 26-40
The intent of this study was to determine the benefits
of 2 months use of adjunctive oral irrigation and au-
tomatic toothbrushing in an adult orthodontic popula-
tion with fixed appliances in place for at least 1 month
in the presence of generalized gingivitis.
MATERIALS AND METHODS
Forty-seven orthodontic patients, between the ages of 21
and 48 years, being treated in an orthodontic clinic in a large
midwestern university were recruited as subjects in this study.
Patients were accepted who had full fixed orthodontic appli-
ances in place. Eight teeth were selected for continued as-

121

122 Burch, Lanese, and Ngan
sessment: two maxillary and two mandibular molars, one
maxillary second premolar, one mandibular second premolar,
one maxillary incisor, and one mandibular incisor. The patient
must have had fixed appliances in place for a minimum of I
month and a diagnosis of generalized gingivitis. The medical
history was reviewed to exclude anyone with a history of
heart murmur, rheumatic heart disease, rheumatic fever, mi-
tral valve prolapse, cardiovascular problems, or history of
any condition that might put them at risk if a bacteremia were
to occur. Patients were excluded if they were pregnant or
planning a pregnancy within the next 3 months, or if they
were taking antibiotics. Subjects were discontinued if they
became pregnant (as determined by menstrual history) or if
they began antibiotic therapy during this investigational
period.
Informed consent was obtained, and patients were ran-
domly assigned to either treatment and control groups, strat-
ifying by sex. One group of 15 subjects served as the control
group. They were instructed to continue cleaning their teeth
and orthodontic appliances in their usual manner of manual
toothbrushing. A second group of 16 subjects was instructed
to use an adjunctive oral irrigation device (WaterPik, Teledyne
WaterPik, Ft. Collins, Colo.) with tap water once per day in
addition to using their usual manual toothbrush. This oral
irrigation device produced a pulsating stream of water with
an exit pressure of 55 to 65 psi, using 400 to 500 ml tap
water for each irrigation.
A third group of 16 subjects was instructed to use the
adjunctive oral irrigation device and an automatic toothbrush
(Plaque Control 2000 by Teledyne WaterPik), once daily with
regular toothbrush. The automatic toothbrush delivered an
elliptical motion similar to the Bass sulcular technique of
manual brushing:'
To calculate the proper sample size, we estimated the
control mean for probe depth at the end of 2 months to be 2
mm, with a standard deviation, SD = 0.45. The mean for
the automatic toothbrush and oral irrigation group was 1.5
and for the oral irrigation and manual toothbrush group was
1.75 with a SD = 0.45 for both groups. With the charts from
Netter and Wasserman." the sample size was calculated at
approximately 15 per group with a power of 0.80 and ex at
0.05.
As for compliance, each subject noted on an assigned
calendar the time of day of the use of the device. Any other
anecdotal information was also noted on the calendar.
Four parameters were measured and recorded for the eight
test teeth of each subject of all groups. Plaque was assessed
by the Silness and Loe plaque index" in which 0 = no plaque
in the gingival area; 1 = a film of plaque adhering to the
free gingival margin and adjacent area of the tooth. The plaque
may be recognized only by running a probe across the tooth
surface; 2 = moderate accumulation of soft deposits within
the gingival pocket and on the gingival margin and! or ad-
jacent tooth surface, which can be seen by the naked eye;
and 3 = abundance of soft matter within the gingival pocket
and! or on the gingival margin and adjacent tooth surface.
Tooth surfaces scored were (1) distofacial, (2) facial, (3)
mesiofacial, and (4) entire lingual gingival marginal surfaces.
American Journal of Orthodontics and Dentofacial Orthopedics
August 1994
Patient indices were calculated by averaging means for each
individual tooth.
Gingival inflammation (GI) was assessed by the Loe and
Silness index." in which 0 = normal gingiva; 1 = mild in-
flammation, slight change in color, slight edema; no bleeding
on palpation; 2 = moderate inflammation, redness, edema,
and glazing; bleeding on palpation; and 3 = severe inflam-
mation, marked redness and edema, ulcerations, tendency to
spontaneous bleeding.
Standard clinical probing was accomplished for the same
four surfaces of the eight teeth. Probe depths were measured
with a standard UNC no. 15 periodontal probe and recorded
to the nearest millimeter demarcation.
Bleeding assessment of the four sites per tooth were made
after probing and varied from the method described by
Muhlemann et al." Thirty seconds after probing, the tooth
surface areas were observed to determine the presence of
bleeding. Any tooth surface area presenting bleeding after the
previous GI index scoring was recorded as a positive reading,
as well as those surfaces presenting a point of bleeding be-
cause of probe depth measurement. This determination was
considered as a bleeding after probing (BAP) assessment.
Bleeding was expressed as number of bleeding points ap-
pearing after GI index scoring and probing of sulcus depth.
Three investigators were trained in assessing all four pa-
rameters. Evaluators were blind to the group designation of
the individual patients.
INTERRATER RELIABILITY
A mixed design analysis of variance was used to estimate
the reliability of the three raters in their assessments of 12
volunteers. This analysis was repeated for each of the four
measurements: plaque index, gingival index, probe depth,
and BAP. The reliability coefficients obtained by these anal-
yses were based on partitioning the variance between and
within subjects and further separating the within subjects com-
ponent into judge differences and residual error as described
by Winer." The coefficients obtained for the plaque index,
gingival index, sulcus depth index, and the bleeding after
probing index were 0.98,0.96,0.62, and 0.97, respectively.
STATISTICAL METHODS
Means and standard errors were calculated for the
three groups at baseline, 1 month, and 2 months for
each of the four outcome measures. Each outcome was
analyzed separately with a 3 by 2 mixed design analysis
of covariance (study group by time). Means at I and 2
months after baseline for the two study groups and
control group were adjusted for baseline values. Dif-
ference between the two oral irrigation groups and con-
trols were compared with Dunnett's t test. Whether
significant differences were found between each of the
oral irrigation groups and the controls, the oral irriga-
tion groups were combined and compared with the con-
trols."
American Journal of Orthodontics and Dentofacial Orthopedics Burch, Lanese, and Ngan 123
Volume 106, No.2

Table I. Difference from baseline for four outcome measures by treatment group and time of follow-up:
Mean differences, standard errors, and p levels*
Automatic brushing plus Oral irrigation plus manual Manual brushing
irrigation (n = 16) brushing (n = 16) only (n = 15)

Outcome measure x
I SE
I p x
I SE
I p x
I SE
I p

Plaque index, I month -0.47 0.07 0.0001 -0.39 0.09 0.0006 -0.07 0.15 0.6372
Plaque index, 2 months -0.47 0.11 0.0008 -0.50 0.11 0.0004 -0.39 0.12 0.0063
Gingival index, I month -0.23 0.07 0.0069 -0.26 0.06 0.0011 -0.12 0.05 0.0459
Gingival index, 2 months -0.42 0.10 0.0010 -0.32 0.06 0.0001 -0.16 0.06 0.0222
Pocket depth (mm) I month -0.30 0.06 0.0002 -0.29 0.10 0.0119 -0.24 0.06 0.0018
Pocket depth (mm) 2 months -0.49 0.10 0.0002 -0.17 0.12 0.2066 -0.23 0.12 0.0743
Bleeding after probing in- -0.21 0.06 0.0030 -0.12 0.04 0.0133 -0.09 0.04 0.0281
dex, I month
Bleeding after probing in- -0.33 0.06 0.0001 -0.23 0.05 0.0002 -0.17 0.06 0.0115
dex, 2 months

OF ratio probabilities from one-way repeated measures ANOYA.

Table II. Adjusted means and standard errors of four outcome measures for three groups of patients by
treatment group and time of follow-up
Baseline One-month Two-month
measure follow-up' fallow-up'

Plaque index
Automatic brushing + oral irrigation (n = 16) 0.90 (0.12) 0.43 (0.10) 0.43 (0.08)
Oral irrigation + manual brushing (n = 16) 0.88 (0.12) 0.50 (0.07) 0.39 (0.07)
Manual brushing only (n = 15) 0.92 (0.12) 0.84 (0.15) 0.53 (0.10)
Gingival index
Automatic brushing + oral irrigation 1.22 (0.08) 0.95 (0.07) 0.76 (0.08)
Oral irrigation + manual brushing 1.16 (0.05) 0.88 (0.09) 0.82 (0.06)
Manual brushing only 1.13 (0.07) 1.02 (0.09) 0.99 (0.08)
Pocket depth (mm)
Automatic brushing + oral irrigation 2.31 (1.3) 1.92 (0.14) 1.73 (0.10)
Oral irrigation + manual brushing 1.99 (0.12) 1.81 (0.12) 1.93 (0.08)
Manual brushing only 2.16 (0.11) 1.92 (0.12) 1.93 (0.09)
Bleeding index
Automatic brushing + oral irrigation 0.47 (0.06) 0.24 (0.05) 0.11 (0.03)
Oral irrigation + manual brushing 0.35 (0.04) 0.25 (0.05) 0.15 (0.02)
Manual brushing only 0.40 (0.07) 0.31 (0.06) 0.23 (0.05)

\djusted by analysis of covariance for differences in baseline measurements.

RESULTS For the plaque index, there were significant differences

Means and their standard errors at baseline, at the
I-month, and 2-month follow-up examinations are pre-
sented in Tables I to III for each of the three study
groups, Changes that occurred over the 2-month study
period reflect marked and significant improvements in
all four outcome categories for the two experimental
groups and the control group. Statistical analyses of the
differences among the three study groups indicated an
experimental effect due primarily to the use of an oral
irrigation device on three of the four outcome measures,
between groups and between the I-month and 2-month
observation periods after adjusting for differences in
baseline scores. Although the interaction of group and
time did not reach significance (p = 0.106), there is
the suggestion that the pattern of change from the first
to the second follow-up examination for the three
groups of subjects may not be the same. Most of the
change between the first month and the second month
occurred in the manual brushing with oral irrigation
group. An examination of the means of the two oral
124 Burch, Lanese, and Ngan
Table III. Summary of repeated measures analysis of covariance of group* and timet effects for four
outcome measures
F ratio: Group
Outcome measure df
\
F
I p
Plaque index 2,42 3.99 0.026
Gingival index 2 3.34 0.045
Pocket depth (mm) 2 0.66 0.523
Bleeding after probing 2 2.39 0.103
*Treatment: Auto brushing and oral irrigation versus oral irrigation and manual brushing versus manual brushing only.
tOne-month versus 2-month follow-up.
irrigation groups suggests that they are equally suc-
cessful in reducing plaque and more successful than the
manual brushing group. However, we were unable to
confirm this by Dunnett's t test, probably because the
two experimental groups had similar mean responses.
When these two groups were combined, however, this
comparison yielded means of 0.44 for the patients using
the oral irrigation device and 0.68 for the patients serv-
ing as controls (t = 2.85, P = 0.007).
Analysis of covariance of gingival inflammation in-
dicated the three groups responded differently to the
prescribed regimens (p = 0.045). There was no sig-
nificant difference between the 1- and 2-month re-
sponses to treatment and no evidence of a group by
time interaction. Again, patients who used the oral ir-
rigation device showed a greater reduction in gingival
inflammation than did the manual brushing control
group. The comparison between the combined exper-
imental groups and the control group yielded means of
0.85 and 1.01, respectively (t = 2.61, P = 0.012).
Probe depth was not substantially reduced by the
experimental procedures, nor was there a significant
change between the l-rnonth and 2-month follow-up
periods. The pattern of change between the two follow-
up examinations was approximately the same for the
three groups. When the two experimental groups were
combined and compared with the control group, means
were 1.85 and 1.93, respectively, a trivial difference
(r = 1.07, P = 0.291). However, inspection of the
changes in group means (Table II) shows the greatest
improvements in pocket depth is achieved in the irri-
gation and power brush group after 2 months. The 0.5
mm improvement measured is approximately twice that
of the other two groups.
The three group means for BAP were not signifi-
cantly different from each other in the mixed design
analysis of covariance, at each examination. However,
there appeared to be fewer points of bleeding after use
of the oral irrigation device (p < 0.0001, 0.0002, and
American Journal of Orthodontics and Dentofacial Orthopedics
August 1994
F ratio: Time F ratio: Group x time
df
\
F
\
p df
\
F
\
p
1,42 5.45 0.024 2,42 2.37 0.106
I 3.19 0.081 2 0.75 0.476
I 0.09 0.762 2 1.84 0.171
I 18.17 0.0001 2 0.034 0.715
0.01). The overall difference between l-month and 2-
month means was highly significant (P < 0.0001) with
fewer bleeding points at 2 months for all groups. When
we combined the two groups that were using the oral
irrigation device and compared them with the manual
brushing group, their respective means of 0.19 and 0.27
were significantly different (t = 2.15, p = 0.037).
Patients who used the oral irrigation device had fewer
bleeding points after probing both at 1 month and 2
months. Again, inspection of the changes in group
means (Table I) shows the most reduction in bleeding
for the irrigation and power brush after 2 months
(p < 0.0001).
DISCUSSION
Significant reductions in gingival inflammation and
plaque were found in the control group, as well as in
both treatment groups. Improvements found in patients
in the control group are not surprising and may be
attributed to the well-known Hawthorne Effect," where
improvement is often measured in a group's usual per-
formance when enlisted in a study and under obser-
vation.
During 2 months of use of the automatic toothbrush
and / or the oral irrigation devices there was significantly
greater reduction of plaque and gingival inflammation
in both treatment (device) groups than in the control
group that used only the normal manual toothbrush.
There was a trend toward reduced numbers of BAP
points. Probing depths did not decrease nor differ
among treatment and control groups.
Although the number of patients participating in this
study was relatively small, highly significant changes
from baseline were observed in all three groups. How-
ever, the magnitude of differences among the three
groups on each of the outcome measures were small.
Nevertheless, these differences created an expected
pattern.
The largest reductions in plaque, inflammation, and
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 106, No.2
bleeding occurred within the first month of investiga-
tion. Further reductions between the I-month follow-
upand the 2-month follow-up were relatively small but
were at significant or nearly significant levels. This
suggests that benefits from using the oral irrigation de-
vice may be experienced early, perhaps in the first week
or two of treatment, and continue beyond the period of
observation of this study.
Although we measured no statistical differences in
probe depths among the three groups over the study
period, it should be noted that our preliminary reliability
study indicated the measurement error was greatest for
probing. Assuming that this measurement error was
nondifferential, its effect would favor the null hypoth-
esis. On the other hand, highly significant changes were
observed from baseline by all three groups. Further-
more,detectable probe depth reduction (gingival sulcus
depth shrinkage) may necessitate more time than 2
months. If maintenance or further decrease in plaque
and gingival scores occurred with time after the 2-
monthevaluation point, gingival shrinkage might occur
and probe depth reduction be more evident. To further
reduceprobe measurement error it is recommended that
future studies refine the technique of measuring pocket
depth, include practice with feedback, and compare
results among raters before engaging in the experiment
itself.
Our assessment of BAP appeared to be higher for
gingivitis patients as compared with bleeding on prob-
ing (BOP) standards for gingivitis patients as described
by Muhlemann et al. 45 The BAP scores as determined
in this study were derived by combining BOP points
with GI bleeding points. Therefore BAP scores were
expected to be greater than BOP scores. The data con-
firmed this assumption.
A recent study by Jackson" reported that there was
no statistically significant benefit to the orthodontic pa-
tient from using an electric toothbrush, a water irri-
gation device, or a combination of the two. In contrast,
the present study shows that daily water irrigation, with
manual or electric brushing, provided significant im-
provement in gingival inflammation and bleeding after
2 months. The benefits of the automatic toothbrush were
not as convincing and must be studied further. More
detail may become evident in further analysis of inter-
proximal versus flat surface conditions. Analysis of the
condition around banded versus bonded molars is being
accomplished and may reveal more specific conclu-
sions.
This study included more patients in each group
than the Jackson study." This fact may partially explain
the statistical differences between the studies. All pa-
tients in this study were adults, possessing a chance for
Burch, Lanese, and Ngan 125
less variability in use and compliance. There was also
a difference in action of the power brushes used in the
two separate studies. The action of the head of the
automatic toothbrush used in this study may be more
effective in removing plaque from around orthodontic
wires, brackets, bands, and auxiliary attachments, than
the power brush tested by Jackson."
The difference attributable to the oral irrigation de-
vice or automatic toothbrush may not be a function of
superiority over the manual toothbrush. Patients may
be attracted to the novelty of the power devices and
clean their teeth with greater intensity and thoroughness
for a longer period of time than if they would when
assigned to the manual brushing only. An improved
study design would prescribe a precise procedure,
length of time and frequency for manual brushing, au-
tomatic brushing, and oral irrigation. Such instruction
to patients would make the study more repeatable by
others and allow comparisons to be made between al-
ternative methods of using these devices. In any case,
the oral irrigation device and automatic toothbrush may
in themselves motivate patients to improve their oral
health.
One-month results of this study have been reported
previously." In conclusion, this current 2-month study
not only shows differences in the four parameters be-
tween baseline and the 2-month follow-up but shows
changes that occurred during the second month of the
investigation. This study indicates that during the sec-
ond month of use, the oral irrigation device, in com-
bination with either the manual or automated tooth-
brush, was of significant value in reducing plaque, gin-
gival inflammation, and bleeding. The short duration
of this study may have limited the findings regarding
pocket depth. However, the group that used daily ir-
rigation and the power toothbrush experienced the
greatest reduction of pocket depth after the 2-month
period (0.5 mm) for this patient population of adults
with fixed orthodontic appliances.
We are grateful to Shirley Carmean, RDH, who was study
coordinator and to Carmen Godfrey for assistance in manu-
script preparation.
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The Ohio State University
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305 West 12th Ave.
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